You Asked, We Answered: Women's Cancers and Breast Health

How much abdominal bloating is cause for concern? I know that it's a key indicator for ovarian cancer. Some days, I'm very bloated and it's painful.

Abdominal bloating is only one of five different symptoms that can be related to ovarian cancer according to a study by Dr. Goff published in 2004. Other symptoms include abdominal pain, back pain, increase in abdominal size and change in urinary habits. Women who presented with ovarian cancer had some or all of these symptoms. There is no specific frequency of bloating that would put you at significantly increased risk, but having it evaluated is reasonable. If you are postmenopausal, a CA-125 test and an ultrasound are appropriate tests to have performed and that can be addressed with your doctor or care provider. If you are premenopausal, an ultrasound alone is a reasonable test.

Hi, I am a 59-year-old female who is single, not sexually active, never have been pregnant and had a hysterectomy in 1989. I have heard stories that anyone who has had a hysterectomy and did not have their ovaries removed (like me) are more than likely to get ovarian cancer. Is that true? I have been living with this question for 21 years. Thank you.

Based on your description, there is no reason to consider yourself at an increased risk of ovarian cancer because you have had a hysterectomy. You still have a risk for ovarian cancer, but it is no different than the general population based on what you describe.

My mom ,who is 85 yrs old, has been complaining of pain in her liver and will go for a blood test in the next few days...Is it cancer?

There is no current evidence that she has cancer. Lab tests, and, if indicated, x-rays, will be helpful.

I'm going out of my mind!! My wife has a lump on her lymph node and a small lump near her nipple. She had a needle biopsy yesterday. Because the node is swollen, does that mean it has now spread into her body? We have been married less than three years and she is the lady of my dreams. Life is so unfair sometimes.

I would need to examine the mass carefully to determine if there is a tumor. Your wife's pathology also needs to be reviewed to be able to make a determination of what the two lumps are and what need to be done about them. Even if there is a tumor in the lymph node, it does not necessarily mean that it is spreading throughout the body.

I need radiation after my breast cancer surgery. Must I take the pral pill too? I forgot its name. I get blood clots.

The pill you refer to is likely a medication that blocks estrogen and progesterone receptors. They can potentially increase development of blood clots. The decision of whether or not to use these will be up to you and your medical oncologist.

I have chronic lymphocytic leukemia (CLL) and have a rash all over my body that has been diagnosed as psoriasis. My gut feeling is this could be cutaneous T cell lymphoma (CTCL). I have changed doctors because of insurance changes and need to see an oncologist. What do you think of my gut feeling?

Given your history of CLL, I think it would be reasonable to follow-up with a medical oncologist in conjunction with a dermatologist for biopsies and futher work-up to rule out CTCL.

What is the chance of breast cancer coming back?

The risk of breast cancer recurrence depends on a number of characteristics of the cancer such as the size of the tumor, how many lymph nodes are involved, if it is hormone sensitive or not, etc. The chance of tumor coming back also depends on the type of treatment you have received such as chemotherapy, hormonal therapy and radiation therapy. The chance of tumor recurrence is highest during the first five years after treatment and gets smaller with the passage of time. Your oncologist should be able to give you a rough estimate of the chance of your cancer coming back based on the particular characteristics of your breast cancer.

Does soy really cause breast cancer? If yes, how much is acceptable to have? Is this at all times or just after menopause?

There is no evidence that eating soy products causes breast cancer. If anything, there is some evidence that young Asian women who eat a higher amount of soy have a lower risk of breast cancer. Soy contains substances called phytoestrogen which behave as weak estrogen (estrogen is the main femal hormone). In women who have had breast cancer, we often try to reduce the level of estrogen and, therefore, there is a concern that eating soy products might counter this effort to reduce estrogen and increase the risk of cancer recurring.

My physician said I need a cervical biopsy. Is she not telling me that I might have cancer? What other reason would there be to do such a test?

Pap smears screen for cervical cancer; having an abnormal Pap smear does not necessarily mean you have cervical cancer. An abnormal Pap smear will prompt a colposcopy which is a visual inspection of the cervix after the application of acetic acid. If an abnormality is seen on the cervix, a biopsy will be performed. I suspect that your physician wants to do the biopsy due to an abnormal pap smear.

I have inverted nipples and wonder if that will mean I cannot breastfeed. What do you think?

Inverted nipples does not mean youcannot breast feed. You can speak to your ob/gyn about techniques to help you learn to breast feed.

One of my nipples is very painful to touch. It almost feels like the pain shoots to the middle of my stomach. What could be wrong?

The question is a difficult one to answer without being able to perform a clinical exam and obtain a thorough family history. There are a number of explanations that could account for nipple pain, although it would be very unusual to radiate to the stomach. The good news is that very rarely does breast/nipple pain go along with a breast cancer. My advice would be to visit your primary care physician, so he/she can put together the symptoms, clinical exam, and family history to best determine the underlying cause and treatment options. If any questions remain, seek the advice of a breast health specialist.

Is it unusual to have three reincisions for breast cancer and have a lumpectomy w/third reincision???

I am assuming that the re-excisions are done for close or positive margins. If that is the case, then most commonly after the second re-excision, a mastectomy is recommended.

I have recently had a mammogram which came back fine. However, in the past week I have had severe pain in my right breast and behind the brest in the bone. Do you think this is cause for concern?

It is very unusual for breast cancer to cause pain in the breast unless it is of the inflammatory type or is affecting surrounding structures. If your breast looks normal and your mammogram is normal, my suspicion for breast cancer would be very low. If the pain persists, it would be a good idea to have it check out by your primary care physician to try to figure it out.

If my mother's mother died of breast cancer, my mother also developed breast cancer, two of her sister also developed breast cancer and my father's sister also developed breast cancer, are my odds and my daughter's for developing cancer a given?

There are many factors that can increase a person's risk for cancer, genetics and family history being one. Having a strong family history does not mean that one will inevitably develop cancer, however their risk may be higher. Approximately 7-10% of breast cancers are hereditary. The majority of hereditary breast cancers are associated with mutations (genetic changes that increase cancer risk) within two high-risk genes known as BRCA1 and BRCA2. In families with multiple generations affected with breast cancer, especially if the diagnosis is before the age of 50, or that have ovarian cancer in the family as well, it maybe recommended to consider testing of these genes through a blood sample. In families where a mutation is found, additional screening options as well as risk reducing surgeries may be discussed. The medical management of families with BRCA gene changes maybe different than what is recommended based just on one's family history alone. If a mutation is found in a family, it also does not mean that every relative has inherited the risk, therefore genetic testing can help clarify which family members should consider high-risk surveillance or risk reduction options and who does not. Families with strong histories of cancer should consider meeting with a genetic counselor to review the risk for a genetic predisposition and discuss the option of genetic testing.

I have a question about ovarian cysts. I'm 24 years old and have just been diagnosed with my first ovarian cysts (the largest of which is 5x5 cm). The problem is, I also have Lichen Sclerosus, Vaginismus, and Vulvadynia. Because of these conditions, I have been seeing a specialist as well as a gynecologist trained in dealing with these issues who are an hour away from where I live. The pain I've been experiencing from the ovarian cysts rarely goes below a 6 and is more often at an 8 level or higher. Yet, neither of these doctors were willing to see me until two weeks after the cysts were found. I have a few questions: 1. How will I know when the cysts have ruptured? Is there just a lot of pain or will something else happen? 2. Is my pain level unusually high for ovarian cysts or is it common? Because I've been in so much pain but unable to see a doctor, I feel as if my doctors don't care about my treatment. To be honest, I'm a little freaked out (because I've never had a cyst before) so I don't know what is reasonable or not for a doctor to do during these circumstances. Should I be looking for a new doctor or is this a normal response for a gynecologist to ovarian cysts (which I realize aren't a big deal). Thanks so much for your answer!

Ovarian "cysts" are very common, indeed. At some level/size, they are a part of every woman's every-day life, especially during the reproductive years when the ovaries are constantly making multiple cysts. Most remain quite small, but some become larger before they spontaneously resolve. That is why for "small" ovarian cysts, assuming no other associated concerns, the recommended treatment is observation, with repeat imaging, often several months later. In general, ovarian cysts are asymptomatic (cause no symptoms). If a woman is having pain, it may or may not relate to the ovarian cyst, but to the extent that it seems to be associated with the cyst, observation alone is not sufficient. Pain relief should be given and consideration of additional evaluation becomes important. As you suggest, some cysts "leak" and that can cause pain. There are other reasons cysts can cause pain as well, including twisting (torsion). Given the degree of your pain, it seems appropriate that you have further evaluation now in hopes of improving the way you feel, as well as gaining an understanding of what the potential problem(s) are.

My breast tissue is very dense and lumpy. When I see my gyn, he always says everything is fine after giving me a cursory exam. I have a mammogram every year which has been negative. I am uneasy because my mother had breast cancer at 60. I am 68. What do you think?

It all depends on how comfortable your gyn is with your breast exam and how your breasts appear on mammogram. The older we get, the "easier" the mammogram is to read as our breast tissue becomes more fatty, but that is not always the case. If you are uneasy, I would recommend seeing a breast specialist to help determine if you are being adequately screened.

Is it possible to get breast cancer again after having a bilateral mastectomy?

Yes, but the risk is very small. There is a very small amount of breast tissue left after a mastectomy, usually attached to the skin. These cancer recurrences present as nodules under the skin that is why it is important to have regular exams by a physician even after a bilateral mastectomy.

My daughter has received the HPV shots. Will she still need pap smear tests?

The answer, currently, is yes. While the HPV vaccine should drastically reduce your daughter's risk of HPV-related cancers and other conditions, there remain occasional problems which are not HPV-related. Furthermore, given that the vaccine is relatively new, there is not a world-wide experience upon which to base future recommendations, such as eliminating pap smears. Over time, and presumably well within your daughter's lifespan, public health officials may feel comfortable stopping pap smears altogether. In the meanwhile, and for the foreseeable future, women will be urged to have occasional pap smears, presumably at widening intervals of time. Your daughter should consult her gynecologist as to evolving recommendations.

Is there a reliable screening test for ovarian cancer?
No, not presently. The tools that we have today are inconsistent in their ability to detect the earliest stages of ovarian cancer. Accordingly, most of the time, when ovarian cancer is picked up by testing, it is already "advanced." There are some "screening strategies" used for women determined to be at high risk for developing ovarian cancer. Their accuracy is not perfect, but for such women, they are still employed. Tumor markers such as CA125 and HE4 (recently developed here at Women & Infants/Brown University) may make screening more feasible. But a women at high risk may still benefit from imperfect screening. As for each individual woman, most of whom are at low risk, the potential benefits to her from screening should be discussed with her physician.

I have a strong family history of colon cancer, but not gynecologic cancer. Even so, I have heard a family history of colon cancer can increase the recent for certain gynecologic cancers. Is this true?

The answer is yes, for some, but, even then, the risk is minimally increased. There are, however, specific genetic syndromes which are known to greatly increase the risk of uterine cancer as well as colon cancer. The most well known is called the Lynch Syndrome, formerly known as HNPCC. In patients/families with HNPCC or Lynch Syndrome, the risk of colon cancer is exceedingly high and the risk of uterine cancer is many times that of the general population. Accordingly, such individuals need special cancer screening programs and, occasionally, prophylactic surgery.

Fortunately, relatively few families are affected by Lynch Syndrome, even if there is a "family history of colon cancer." However, if an individual has cases of colon cancer or other cancers in their family, they should speak with their physician who may seek further consultation with a trained genetic counselor. Dr. Robert Legare is director of our genetics program and an expert resource for anyone concerned about their genetic risks and what actions they can take to reduce risk. Dr. Legare can be reached at 401-453-7540.

I am hearing about many women who are opting for double mastectomy rather than lumpectomy and radiation. Wasn't the latter proven to be as effective a treatment for breast cancer?

Lumpectomy plus radiation is as effective as mastectomy for treatment of breast cancer. Some women are at higher risk for developing another breast cancer in the future (due to personal or family history) and choose to have bilateral mastectomy to reduce that risk. That is an individual decision and not a medical necessity.

I had two mammograms in a week and several cysts on my breast - is this normal?

Simple breast cysts are very common especially if you are peri-menopausal. Additional mammogram views and ultrasound are appropriate to evaluate them. The majority of them are benign (non-cancerous) and require no other follow-up. If they are large or cause pain the fluid can be drained with a needle.

Is family history a major factor in diagnosing gynecologic cancer?

There is not a simple answer. As we learn more about genetics, we will almost certainly find many new answers for age-old problems, including cancer. Presently, we know relatively little about genetics, but even at that, there are many important insights that explain risks for certain cancers. Therefore, family history, which is in some ways a question of genetics, is an important risk factor, but, presently, only for a relatively few malignancies, and then only in relatively few patients.

Currently, we are only aware of strong family history/genetic relationships playing a role in a surprisingly small percent of gynecologic cancers, including breast, ovary, and uterus. In other words, most women who develop gynecologic and breast cancers do not have a perceivable family history or genetic risk (that we can determine). Accordingly, the vast majority of women who develop gynecologic malignancies seem to develop them "sporadically," which means they seem to come out- of- the-blue, even though there are undoubtedly explanations that contemporary medicine does not yet understand.

Having said this, family history is an important part of health care for today's women (and men). There are many known risk factors for malignancy, including family history, with an underlying genetic explanation. One of the most well-known is BRCA1 and 2. Women with a family history of breast and/or ovarian cancer, particularly first-degree relatives, where these malignancies started at a young age, may be themselves at a significantly higher risk of developing those cancers. After a woman speaks with a qualified genetic counselor, who will obtain a detailed family history, the potential usefulness of genetic testing can be determined, and in women found to have a BRCA mutation, the risk of breast and ovarian cancer can be exceedingly high. The health care strategies women at high risk follow are important in protecting their lives and might not otherwise be taken if their increased risk is not identified through their family history.

Therefore, family history is an important risk factor for everyone, but, as of 2010, most people, as judged by today's "tools," will find that their family history is "normal," predicting an average risk for malignancies as opposed to those with BRCA1 and 2 positivity.